Feto-amniotic shunting -- experience of six centres

AIM

Foeto-amniotic shunting is an ultrasound-guided, therapeutic intervention for drainage of persistent intracavital fluid retention in severely affected foetuses with a high risk of mortality. In order to weigh up the comparatively high risk of intervention against the possible benefit, we evaluated the value of different indications, the complication rate and the time span of drains in situ.

PATIENTS AND METHODS

We made a survey of all level III ultrasound centres of German-speaking countries from 1993 to 2001. Six level III centres returned the questionnaire: forty-seven foeto-amniotic shunting procedures were performed in 30 foetuses [megacystis in 18 foetuses (three of these with urinary ascites), hydrothorax in eight foetuses, hydronephrosis in two foetuses, cystic adenomatoid malformation of the lung in one foetus, ovarian cyst in one foetus].

RESULTS

The median gestational age at time of shunting was 23.5 (range 16 - 33) weeks, at time of delivery 35 (range 23 - 41) weeks. The median time span of drains in situ was 19 (range 0 - 170) days. Altogether 18 of 30 foetuses (60 %) had a benefit of foeto-amniotic shunting.

CONCLUSION

The best possible selection of pregnancies which might profit from foeto-amniotic shunting is required. The decisive criteria are the underlying defect as well as the severity and progression of the disorder.

The clinical impact of magnetic resonance imaging in fetuses with central nervous system anomalies on ultrasound scan

OBJECTIVES

Magnetic resonance imaging (MRI) was performed on fetuses with sonographically diagnosed central nervous system (CNS) anomalies to determine frequency and type of cases in which fetal MRI adds clinically relevant information.

PATIENTS AND METHODS

Forty-three cases presenting with CNS anomalies by ultrasonography were investigated by MRI. The potential effect of MRI on parental counseling and pre- or postnatal management were the main endpoints.

RESULTS

Fetal MRI confirmed the sonographic diagnosis in 28 of 43 cases, showed additional findings in 14 of 43 cases, and was inferior to sonography in 1 of 43 cases. The MRI diagnosis had therapeutic consequences in 11 of 43 patients, with the fetal MRI diagnosis influencing parental counseling in 8 of these 11 patients. Prenatal patient care was not influenced by the additional investigation with fetal MRI.

CONCLUSION

MRI is well suited as additional imaging method in fetuses with CNS anomalies. Additional fetal MRI is particularly indicated if the findings might have a therapeutic consequence.

Fetal skeletal deformities - the diagnostic accuracy of prenatal ultrasonography and fetal magnetic resonance imaging

OBJECTIVE

To evaluate the diagnostic accuracy of prenatal ultrasonography and fetal magnetic resonance imaging (MRI) in fetuses with skeletal deformities (SD).

METHODS

Fourteen pregnant women of 21 - 34 weeks of gestation whose fetuses had SD on prenatal ultrasound (seven fetuses with spina bifida, four with complex malformation syndrome, two with scoliosis, and one with chondrodysplasia) were additionally investigated by fetal MRI using a 1.5T superconducting system with T1-and T2-weighted sequences in three section-planes. Main outcome measures were diagnostic accuracy, potential effect on parental counselling and influence on perinatal management of the additional investigation with fetal MRI.

RESULTS

In 10 cases ultrasound had a better diagnostic accuracy than MRI concerning the diagnosis of SD. In four cases with spina bifida MRI provided additional information towards preoperative evaluation for neurosurgery. In five cases parental counselling was improved. There was no influence on perinatal management.

CONCLUSION

MRI may provide additional information to ultrasound scan in fetuses with spina bifida and consecutive neurosurgery; in fetuses with other skeletal deformities additional information may be expected only in rare cases.

Foetal facial clefts: prenatal evaluation of lip and primary palate by 2D and 3D ultrasound

INTRODUCTION

To examine whether three-dimensional ultrasound (3D US) is an accurate diagnostic method of clinical use in the ability to define the location and extent of facial clefting prenatally, compared to two-dimensional ultrasound (2D US).

METHODS

18 foetuses suspected or diagnosed to suffer from a facial cleft by 2D US were examined with a targeted 3D US. 2D US and 3D US results were compared with postnatal outcome.

RESULTS

Comparison of the number of foetuses with a cleft lip + primary palate diagnosed correctly with 2D US with the results of adjunctive 3D US (true positive + true negative) showed that adjunctive 3D US correctly diagnosed more cleft lips (100 %; 15/15 foetuses vs. 66 %; 12/18 foetuses) and more cleft primary palates (100 %; 12/12 foetuses vs. 58 %; 7/12 foetuses).

CONCLUSION

Interactive review of standardised 3D multiplanar images allows to systematically evaluate lip defects and abnormalities of the maxillary tooth-bearing alveolar ridge. The accuracy of adjunctive 3D ultrasound is superior to 2D ultrasound alone for extensive prenatal diagnosis of cleft lip with or without cleft primary palate.

Prenatal diagnosis of a giant foetal lymphangioma and haemangiolymphoma in the second trimester using 2D and 3D ultrasound

Lymphangiomas are benign tumours of the lymphatic system. Early prenatal diagnosis is important to permit a planned delivery and provide adequate postnatal care. It thereby improves prognosis and allows the option of terminating the pregnancy if poor outcome is predicted. We report two cases, a giant haemangiolymphoma and a lymphangioma. 2D and 3D US findings are presented and differential diagnosis, therapeutic options and prognosis are discussed.

Fetal ovarian cysts: development and neonatal outcome

INTRODUCTION

The aim of the study was to evaluate the outcome of fetal ovarian cysts in relation to their size and ultrasonic appearance.

METHODS

We retrospectively analysed pre- and postnatal charts of 61 infants with a prenatal diagnosis of ovarian cysts between 1991 and 2000.

RESULTS

In a total of 61 fetuses 65 ovarian cysts were detected by transabdominal ultrasound: 35 (57 %) cysts on the left side, 22 (36 %) on the right side and 4 fetuses (7 %) had bilateral cysts. Three patients with uncomplicated cysts were lost to follow-up and one fetus with bilateral cysts died in the 27th week of gestation. In 17 cysts treatment was necessary. 14 cysts (all complicated) were operated after delivery because of persistence or enlargement. The histological results were either follicular or theca lutein cysts in 12 cases, one lymphangioma and one teratoma. Two cysts were aspirated in utero and one after delivery. In the remaining 40 fetuses, 43 cysts where only controlled by ultrasound. 8 cysts regressed before delivery and 35 cysts after delivery independent of their sonographic appearance. The mean diameter of cysts that required treatment was significantly different from the mean diameter of cysts that resolved spontaneously (6.8 [SD 2.4] cm vs. 3.3 [SD 0.8] cm; p < 0.01).

CONCLUSION

Complicated cysts which do not regress should be treated either by laparotomy or laparoscopically after delivery. Uncomplicated cysts which exceed 5 cm could be treated by in utero aspiration or aspiration after delivery to avoid further complications. Cysts smaller than 5 cm, presenting the tendency to regress, should be left untouched independent of their sonographic appearance.

[The intrauterine rupture of the fetal bladder as a complication of low urinary tract obstruction]

Lower urinary tract obstruction in fetuses causes megacystis, megaureter and hydronephrosis. The spontaneous rupture of the fetal bladder represents a rare complication in cases of total bladder outlet obstruction. We report about two different cases, present pre- and postnatal therapeutic regimes and discuss the possibility of spontaneous healing of a ruptured fetal bladder before delivery.

Dandy-Walker malformation as sonographic marker for fetal triploidy

Fetal triploidy is a frequent reason for early abortion, and only few fetuses survive into the second trimester of pregnancy. Common sonographic markers for triploidy in the second trimester are severe asymmetric growth restriction (triploidy of maternal origin) and partial molar changes of the placenta (triploidy of paternal origin), together with structural fetal malformations. We report prenatal sonographic findings of thirteen triploid fetuses between 18 and 34 weeks' gestational age (eleven fetuses with 69, XXX, and two fetuses with 69, XXY). Intrauterine growth restriction (11/13 fetuses), oligohydramnios (8/13), bilateral cerebral ventriculomegaly (6/13), structural heart defects (4/13), and Dandy-Walker malformation or Dandy-Walker variant (4/13) were the most frequent findings. We conclude that the Dandy-Walker malformation and Dandy-Walker variant should be considered as additional sonographic markers for fetal triploidy.

Combined prenatal ultrasound and magnetic resonance imaging in two fetuses with suspected arachnoid cysts

Sonography and ultrafast magnetic resonance imaging were used in the prenatal assessment of two fetuses with sonographically suspected arachnoid cysts. In one case magnetic resonance imaging confirmed the ultrasound diagnosis, in the other case magnetic resonance imaging revealed the presence of a midline cyst associated with dysgenesis of the corpus callosum. Ultrafast magnetic resonance imaging is a useful supplementary imaging method in the evaluation of pregnancies complicated by fetal cerebral anomalies.

Abnormal vaginal bleeding as first symptom of acute leukemia

We report a case of a 37-year-old woman, presenting with vaginal hemorrhage, together with severe anemia and thrombocytopenia (hematocrit: 10.6%; platelets: 6 G/l) caused by previously unknown acute lymphocytic leukemia.

The role of oxytocin in relation to female sexual arousal

Oxytocin is clearly involved in human reproduction and serves an important role in sexual arousal. Oxytocin serum levels were measured before and after sexual stimulation in 12 healthy women. Values of oxytocin 1 min after orgasm were significantly higher (p < 0.05) than baseline levels. This finding supports the hypothesis that oxytocin plays a major part in human sexual response both in neuroendocrine function and postcoital behavior.

Melatonin in postmenopausal females

There is little information about the interaction between melatonin, sexual steroids and neuroendocrine system in postmenopausal females, even if former research showed that melatonin is clearly involved in human physiology and pathophysiology. We evaluated the overnight urinary excretion of 6-sulfatoxymelatonin (6-SMT) using a radioimmunoassay in 60 postmenopausal women. The group has been divided into patients with insomnia (10), hyperprolactinemia (7), depression (9), obesity (7) and controls (27). Compared to controls 6-SMT values were significantly higher in depressive females. Patients with hyperprolactinemia showed a trend toward a significantly elevated average nocturnal melatonin concentration. Melatonin levels were significantly lower in patients with insomnia and obese postmenopausal females than in controls. Since previous studies described lower melatonin levels in postmenopausal than in premenopausal women, the indication of melatonin therapy, especially for sleep disorders in this collective, can be handled more generously. Melatonin should be prescribed restrictively in patients with depression and in those with hyperprolactinemia. The role of melatonin in obese females remains unclear.

Acardiac twin pregnancy: associated with trisomy 2: case report

Acardiac anomaly is a rare complication of multiple pregnancies. Arterial-to-arterial vascular anastomoses between twins, in the presence of a fused placenta, develop in the first trimester. Consequently the pump twin provides the acardius with blood. The second case of acardiac twin pregnancy with cytogenetic analysis of the acardiac showing the karyotype 47,XX,+2 is presented. Literature of acardiac twin pregnancies with different cytogenetic results and cases with trisomy 2 are reviewed, and a hypothesis of genesis is put forward.

[Applications of cerebral MRI in neonatology]

Magnetic resonance tomography (MRT) has become the most important method in the workup of infantile cerebral complications after primary sonography. Cerebral MR examination and image interpretation during the infantile period require extensive knowledge of morphological manifestations, their pathophysiological background, and frequency. The choice of imaging parameters and image interpretation is demonstrated in infarctions and hemorrhages of the mature and immature brain. A review of the main differential diagnoses is also given. The relevance of MR spectroscopy and fetal MRI is discussed.

Endocrinological disorders. Focusing on melatonin's interactions

BACKGROUND

The interaction of melatonin to sterility and anovulation as well as related hormonal disorders has not been sufficiently examined yet. We set out to investigate the interaction between melatonin and hyperprolactinemia, hyperandrogenemia, hypothyreosis and obesity in premenopausal females.

METHODS

We evaluated the overnight urinary excretion of 6-sulfatoxymelatonin (6-SMT) in a group of 155 women using a radioimmunoassay.

RESULTS

Melatonin levels in patients with hyperprolactinemia and hyperandrogenemia with normal body mass index are significantly higher compared to matched controls. Obese females without hormonal disorders showed statistically lower 6-sulfatoxymelatonin levels and in hypothyreotic females we found no difference in 6-sulfatoxymelatonin levels compared to controls.

CONCLUSION

Melatonin plays an important role in patients with hormonal disorders such as hyperprolactinemia and hyperandrogenemia. Melatonin should be prescribed restrictively in all sterile patients. In patients with untreated hypothyreosis or obesity, melatonin seems to play a minor part; in those with hyperprolactinemia and hyperandrogenemia additionally to standard sterility treatment light therapy may improve the outcome.

Ultrasound evaluation of fetal spine length between 14 and 24 weeks of gestation

The objective of our study was to establish a nomogram of fetal spine length in the second trimester of pregnancy by using two and three-dimensional ultrasound. Fetal spine length was measured prospectively by means of transabdominal ultrasonography in 114 normal singleton pregnancies between 14 and 24 weeks of gestation. Regression analyses were performed on spine length, gestational age, biparietal diameter and femur length. Supplementary three-dimensional ultrasound to assess fetal spine length was performed in 75 cases. Fetal spine length, as a function of gestational age, was expressed by the following regression equation: spine length (mm) = -47.2 + 7.16 x gestational age (weeks), with a Pearson correlation coefficient of R(2)=0.956. The results of the measurements revealed no difference between two and three-dimensional ultrasound. Our study defines the normal limits of fetal spinal length in the second trimester of pregnancy and demonstrates a high correlation between spinal length, gestational age, biparietal diameter and femur length. However, there are still too few prenatal research data to say whether and to what extent an assessment of fetal spine length at this stage of pregnancy can be used for prenatal diagnosis of congenital syndromes, which, among other manifestations, are marked by fetal spine lengthening or shortening.

Hepatic perfusion after liver transplantation: noninvasive measurement with dynamic single-section CT

PURPOSE

To compare hepatic perfusion values after orthotopic liver transplantation with those in healthy volunteers.

MATERIALS AND METHODS

Dynamic single-section computed tomography (CT) of the liver was performed in 50 participants, including 30 study patients who had undergone orthotopic liver transplantation and had no clinical evidence of postoperative complications (mean age, 53.7 years) and 20 healthy volunteers (control subjects) (mean age, 59.0 years). CT scans were obtained at a single level to include the liver, spleen, aorta, and portal vein. Scans were obtained over 88 seconds (one baseline scan followed by 16 scans every 2 seconds and, then, eight scans every 7 seconds) beginning with the injection of 40 mL of contrast agent (flow rate, 10 mL/sec). On each CT scan, the attenuation of these organs was measured in regions of interest to provide time-attenuation curves. From these data, the arterial, portal venous, and total perfusion of the liver were calculated, and the hepatic perfusion index was assessed.

RESULTS

In control subjects and study patients, respectively, mean arterial hepatic perfusion was 0.16 and 0.25 mL/min/mL (P = .001 [two-tailed paired Student t test]), mean portal venous perfusion was 1.22 and 1.26 mL/min/mL, mean total liver perfusion was 1.38 and 1.50 mL/min/mL (difference not significant), and the mean hepatic perfusion index was 0.12 and 0.16 (P = .002).

CONCLUSION

Arterial hepatic perfusion was significantly increased after orthotopic liver transplantation, but differences in portal venous and total liver perfusion were not significant. Dynamic single-section CT might also help evaluate hepatic vascular complications, chronic transplant rejection, and hepatic perfusion in liver cirrhosis.

The effect of hydroxyethyl starch on platelet aggregation in vitro

The effect of hydroxyethyl starch (HES) on hemostasis seems to be minimal when it is used in recommended amounts. A number of studies have investigated the effect of HES on platelet function when administered in vivo, but there has been no study investigating the effect on the isolated platelet function when administered in vitro. A photometrical method to assess platelet function in platelet-rich plasma (approximately 250 x 10(9) platelets/L) was used with platelet aggregation induced using either collagen, epinephrine, adenosine diphosphate, or ristocetin. We found a dose-dependent decrease of platelet aggregation in vitro with either collagen or epinephrine, but not with adenosine diphosphate or ristocetin. However, the changes of HES on platelet aggregation were detected only in doses larger than those routinely used in the clinical setting. Therefore, we conclude that the influence of HES at the recommended doses on initial platelet aggregation may not be clinically relevant.

IMPLICATIONS

The effect of hydroxyethyl starch on platelet function and coagulation is discussed. This study showed no influence on platelets in clinically relevant doses in an in vitro model.